Smokers with a history of anxiety disorders have an impaired ability to quit smoking and fail to respond to cessation pharmacotherapy that is usually effective in smokers without such a history, new research suggests.

“These findings have considerable clinical relevance,” write Megan Piper, PhD, from the University of Wisconsin School of Medicine and Public Health and the Center for Tobacco Research and Intervention in Madison, and her colleagues.
“This work suggests that clinicians and researchers should assess anxiety disorder status if they wish to predict patients’ withdrawal and likelihood of achieving abstinence,” the study authors add.

The study was published online October 25 in Addiction.

Medication Not Enough

“The most important thing right now for clinicians is that medication is definitely not enough for your smokers who have a history of panic attacks, social anxiety, or generalized anxiety,” Dr. Piper told Medscape Medical News.

“Suggesting that they quit smoking and giving them medication, which would be 2 absolutely perfect interventions for someone without a history of anxiety, is really not going to do much for these folks because they do not appear to respond to the medication,” she added.

There has been relatively little research on the relationship between anxiety disorders and tobacco dependence and smoking cessation, Dr. Piper noted. Instead, most research has focused on the association between smoking and schizophrenia or depression.

To address this research gap, she and her colleagues studied smokers with panic attacks, social anxiety disorder, and generalized anxiety disorder, as well as smokers who had no anxiety diagnosis, and then followed up these smokers as they attempted to quit.

Most smoked an average of 21 cigarettes per day, had their first cigarette at the age of 14 years, and began smoking daily at the age of 17 years.

All medications were provided for 8 weeks after the quit date except the nicotine lozenge, which was provided for 12 weeks as per prescribing instructions.

A structured clinical interview identified 455 subjects who ever met criteria for a panic attack, 199 for social anxiety, 99 for generalized anxiety disorder, and 891 subjects with no anxiety diagnosis.

Smokers with anxiety were less likely to be abstinent at 8 weeks and 6 months after the quit date than smokers with no anxiety. They also showed no benefit from single-agent or combination-agent pharmacotherapies.

Smokers with anxiety also reported higher levels of nicotine dependence and withdrawal symptoms before quitting and also experienced more negative feelings on their quit day than their counterparts without anxiety.

Further, smokers without anxiety achieved the best results with the nicotine patch and nicotine lozenge combination. Bupropion (Zyban) alone or in combination with the nicotine lozenge was also effective in this group.

Dr. Piper said she was very surprised by the study findings.

“We were definitely surprised at our results. The study looked at 5 different active treatments, and the combination of the nicotine patch was the most effective and had the highest abstinence rates at our 6-month outcome point,” she said.

“One would expect that everybody would be benefiting. To see a rather large group — almost a third of our sample had some sort of anxiety history — not responding at all to those medications was a surprise.”

Clinicians should recognize that this population of smokers should be offered, or referred to, counseling, Dr. Piper said. Clinicians who not feel qualified to counsel people on smoking cessation should refer them to the national quit line at-1-800-QUIT-NOW, she suggested.

An “Open Secret”

The finding that people with anxiety disorders have a hard time quitting cigarettes and are resistant to cessation medications is “an open secret,” said Alexander Obolsky, MD, assistant professor of clinical psychiatry at Northwestern University Medical School in Chicago, Illinois.

“Clinicians who treat people with anxiety disorders know this,” he told Medscape Medical News. “If you have a person who has a psychiatric condition and a comorbid substance abuse disorder, then treating the underlying psychiatric condition is paramount if you are going to have any success in obtaining drug use cessation.”

Dr. Obolsky also said that a one-size-fits-all approach to counseling these patients is not going to work.

“The difficulty is that from a public health perspective and from the scientific perspective, people often focus on large populations and the actual occurrence of treatment does not occur with populations,” he said.

“The actual occurrence occurs with Mr. John Jones, a 45-year-old man who may be a little overweight, unhappy about his marriage, who may have very idiosyncratic, very personal reasons for smoking.

“The issue is to figure out whether or not the patient is feeling that the smoking of cigarettes is helping to alleviate some of the symptoms of social anxiety. If it does, it will do me no good to try to persuade this person to quit smoking if they still have social anxiety,” said Dr. Obolsky.

Taking a good history is imperative, he added. “You need to understand your patient’s mental functioning going very far back. Smoking is not just a chemical dependency; it is a psychological dependency as well. Once you have a good history, then you can develop a more thoughtful approach to treatment.”

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